Too critical to collapse: Today’s primary care crisis

As our nation recovers from one of the greatest public health emergencies in a generation, not enough attention is being paid to a longer brewing and dangerous trend in U.S. health care: the deterioration of our country’s primary care workforce. 

Primary care serves as the frontline of U.S. health care — and is the only health care service associated with improved population health and fewer health inequities. It does this with just under one-third of the health care workforce and less than one-tenth of health care dollars. 

Failure to attend to primary care will not only guarantee a continuation of hospital labor woes and stretched resources, but will also threaten our country’s health security, including our capacity to respond to a future pandemic and to assure all people in America have a shot at long and healthy lives.

Primary care, which includes the fields of family medicine, internal medicine and pediatrics, is defined as health care provided by interprofessional teams that are accountable for addressing the majority of an individual’s health and wellness needs across settings and through sustained relationships. The field has been largely ignored by policymakers, even though during the pandemic lockdown many practices converted to telehealth within days and stepped up to provide additional services like behavioral health and dental care.

A recent national report from the Milbank Memorial Fund underscores the urgent need to address a primary care system in crisis, finding:

• Growing workforce shortage: One in three U.S. physicians practiced primary care in 2010, yet only one in five medical residents (20 percent to 21 percent) entered primary care between 2012 and 2020.
• Systemic underinvestment: The U.S. invested less than 6.5 percent of total health spending on primary care between 2010 and 2020.
• Too few physicians training in community settings: Some states are training only 7.5 percent of their residents in medically underserved areas and rural counties, where most primary care is delivered. 
• Data gaps: A lack of timely, disaggregated data hinders the accurate measurement and implementation of high-quality primary care at the national and state levels.

Almost half of surveyed primary care clinicians attest that U.S. primary care is crumbling. With focused attention and decisive action, we can fix it.

Achieving high-quality primary care for all will require purposeful steps guided by evidence and data to address our underinvestment in primary care. The solutions start with the Centers for Medicare and Medicaid Services and state authorities increasing the portion of overall spending going to primary care. These payments should foster team-based person-focused care, not just more office visits to physicians. Majorities of surveyed physicians say that reimbursement for responding to questions through emails, texts or telephone calls and partnerships to foster preventive health would improve the state of primary care. 

To increase the supply of primary care clinicians, health care organizations and local, state, as well as federal government agencies should expand and diversify the primary care workforce, particularly in areas with shortages of medical professionals. Current federally funded training programs should be augmented and revised to add more primary care training slots and put more emphasis on community-based training, including training in rural counties and some urban communities.

Health care is our nation’s fourth largest industry and primary care is its largest platform — we can no longer survive its virtual invisibility to policymakers. The public sector not only provides $12 billion to $14 billion annually for graduate medical education of physicians through Medicare and Medicaid payments, but also foots half the health care bill in the country. 

An Office on Primary Care in the Department of Health and Human Services would help align initiatives, including graduate medical education, Medicare reimbursement and more. A federal office could also support beleaguered primary care clinicians by coordinating workforce training, behavioral health integration, clinical comprehensiveness and payment. 

Ensuring everyone has access to a “usual source of care” — one usually found in the primary care offices — is fundamental to a healthy, secure future. Rather than respond to those in the health care industry with money and power, we will need to focus on the crisis in the health care sector we all need first and most: primary care.

Christopher F. Koller is president of the Milbank Memorial Fund.

Rebecca Etz is a professor of Family Medicine and Population Health and Virginia Commonwealth University and codirector of the Larry A. Green Center.